A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

Check the client's distal pulses in both legs.

Keep the client overnight.

Keep the client on bed rest for 12 hr.

Restrict the client's oral fluids.

Answer and Explanation

The Correct Answer is A

A. Check the client's distal pulses in both legs:

Checking the client's distal pulses in both legs is crucial to ensure that there is adequate blood flow and no signs of arterial occlusion or complications from the catheterization. This is an important assessment to detect potential vascular complications, such as a hematoma or an arterial blockage.

B. Keep the client overnight:

Keeping the client overnight is not typically required for all cardiac catheterization procedures. The need for an overnight stay depends on the individual case and any complications or comorbidities. Routine catheterizations often allow for discharge on the same day with appropriate monitoring.

C. Keep the client on bed rest for 12 hr:

Keeping the client on bed rest for 12 hours is excessive. Typically, bed rest is required for 2 to 6 hours following the procedure to allow the puncture site to stabilize and reduce the risk of bleeding. The exact duration of bed rest depends on the approach used and the patient's condition.

D. Restrict the client's oral fluids:

Restricting the client's oral fluids is generally not appropriate. In fact, increasing fluid intake is often encouraged to help flush out the contrast dye used during the procedure and to prevent renal complications. Monitoring for fluid balance is important, but outright restriction is not typically indicated unless there is a specific medical reason.

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Correct Answer is C

Explanation

Answer: C. Respiratory acidosis

Rationale:

A) Metabolic acidosis: This occurs when there is an excess of acid in the body or a loss of bicarbonate, often due to conditions such as renal failure or severe diarrhea. In chronic bronchitis, the primary issue is related to respiratory function rather than metabolic disturbances.

B) Respiratory alkalosis: This condition results from hyperventilation, leading to excessive loss of carbon dioxide. It is unlikely in a client with chronic bronchitis, who typically experiences difficulty in exhaling fully rather than hyperventilating.

C) Respiratory acidosis: In chronic bronchitis, airflow obstruction and reduced gas exchange can lead to carbon dioxide retention, resulting in respiratory acidosis. Symptoms like dyspnea and increased work of breathing support this imbalance, as the body is unable to adequately expel carbon dioxide.

D) Metabolic alkalosis: This imbalance results from excessive bicarbonate or loss of hydrogen ions, often related to prolonged vomiting or diuretics. It is not characteristic of chronic bronchitis, where the primary concern is respiratory function rather than metabolic processes.

A. Increase the heat in the client's room. B. Perform nasotracheal suctioning for the client. C. Place the head of the client's bed flat. D. Administer an opioid narcotic to the client.

Correct Answer is D

Explanation

(A) Increase the heat in the client’s room: Increasing the heat in the client’s room is not typically recommended for a client experiencing dyspnea. Heat can sometimes make breathing more difficult, and it does not address the underlying cause of the dyspnea.

(B) Perform nasotracheal suctioning for the client: Nasotracheal suctioning can be used to clear the airway in certain situations, but it is not typically the first-line treatment for dyspnea in a client at the end of life. It can be uncomfortable and distressing for the client.

(C) Place the head of the client’s bed flat: Placing the head of the bed flat can actually make breathing more difficult for a client experiencing dyspnea. It is generally more helpful to elevate the head of the bed to facilitate easier breathing.

(D) Administer an opioid narcotic to the client: This is the most appropriate answer. Opioid narcotics can help to relieve dyspnea in clients at the end of life by reducing anxiety, decreasing the sensation of breathlessness, and improving the client’s overall comfort level. The use of opioids in this context should be carefully monitored to manage potential side effects.

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A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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